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Abstract: The patient had a subacute onset with persistent dizziness, headache, and head distension, with fair sleep at night, denial of emotional anxiety and stress, denial of history of infection, previous smoking habit, history of hypertension, magnetic resonance imaging of the head showed bilateral cavernous infarcts, cranial magnetic resonance artery imaging showed: cerebral arteriosclerotic stenosis, and cerebral ischemia was considered as the cause. The patient was discharged successfully.
Basic information】Female, 50 years old
Disease Type】Cerebral ischemia
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】January 2022
Treatment plan】Medication (Danshen Chuanxiongzin injection, ShuXinNing injection, Nourishing blood and clearing brain granules, Waking brain Jing injection, Amlodipine benzoate tablets, Metformin hydrochloride tablets, Rosuvastatin tablets)
Treatment Period】7 days of hospitalization
Treatment effect] Clinical symptoms were relieved, recovery was good, and the patient was discharged successfully.
I. Initial consultation
The patient complained of persistent headache, pulsating pain and dizziness, accompanied by nausea and vomiting, and initially thought it was cervical spondylosis. The patient was asked: no limb weakness, no clumsy speech, no convulsive episodes, and a CT examination of the head showed bilateral cavernous infarction, and was admitted to the hospital. The patient had a past history of hypertension, diabetes mellitus, hyperlipidemia, and a past history of smoking for 10 years with an average of 10 cigarettes/day. After admission, physical examination was performed: body temperature: 36.5℃, blood pressure 170/100mmHg, heart rate 75 times/min, respiration 18 times/min. The patient was clear, fluent in speech, normal limb movement, and normal sensation. Perfect head MRI showed: multiple lacunar cerebral infarction, cerebral arteriosclerotic stenosis, and preliminary diagnosis of cerebral ischemia.
(Head MRI)
II. Treatment process
We explained to the patient and his family about his condition, and the current priority was to control the risk factors of cerebrovascular disease. So we chose to give the patient the following medications: Danshen Chuanxiongzin Injection, Nourishing Blood and Clearing Brain Granules, Shuxining Injection to help improve circulation; Awakening Brain Jing Injection to protect brain tissue; Amlodipine Benzoate Tablets to control blood pressure; Metformin Hydrochloride Tablets to control blood sugar; Rosuvastatin Tablets to control blood lipids.
III. Treatment effect
After 7 days of IV and oral drug treatment, the patient’s headache, dizziness and head swelling symptoms were relieved, the pain was limited to the forehead, and the uncomfortable time per day was reduced; the patient’s blood pressure was well controlled and basically could be controlled under 140/90 mmHg; blood glucose control was fair, fasting blood glucose was controlled under 7 mmol/L; follow-up review was needed for lipids, and the patient reached the discharge criteria and was advised to One month later, the patient’s symptoms of dizziness, headache and head swelling basically disappeared.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but because the patient has persistent headache, head distension, dizziness, previous hypertension, diabetes and other underlying diseases, check head MRI without acute stage cerebral infarction, cerebrovascular atherosclerotic stenosis, consider cerebral ischemia cerebral blood supply insufficiency caused. Therefore, we need to pay attention to eating less food with high salt, sugar and fat, including fatty meat and animal offal, quit smoking and drinking more water in our life. In addition, it is important for patients with cerebral ischemia to get enough sleep, and they should keep an optimistic attitude and pay attention to rest. Measure blood pressure several times a day, take oral antihypertensive drugs regularly, monitor blood sugar before and 2 hours after three meals and at bedtime regularly, and visit the endocrinology department to regulate blood sugar after subsequent improvement of dizziness and headache symptoms. Regularly review bilateral carotid ultrasound to clarify the size of carotid plaque and the degree of stenosis.
V. Personal insight
The cerebral vasculature is mainly divided into two major vascular systems: the anterior and middle cerebral arteries, and the posterior circulation is mainly divided into the basilar and posterior cerebral arteries. This case shows that patients with cerebral insufficiency and cerebral ischemia are very common in outpatient clinics, especially those who are middle-aged or above and have previous risk factors for cerebrovascular disease, such as hypertension, diabetes, hyperuricemia, hyperlipidemia, as well as long years of smoking and drinking, etc. The head MRI can be improved to clarify. In addition, patients with cerebral ischemia are reminded that they should be carefully differentiated from diseases such as vegetative nerve dysfunction, cerebral infarction, cerebral hemorrhage, and meningitis.